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Provider Quick Alert

January 23, 2026
Review all Medical Coverage Policies at QualChoice.com.
Pharmacy Policy Changes - January 2026

Medical Policy Number
 Medical Policy Name Effective Date of Change Description of Changes
CP.PHAR.115
Pegloticase (Krystexxa) 06/01/2026 1Q 2026 annual review: removed losartan as a uricosuric agent as its place in therapy is an antihypertensive alternative to HCTZ; added combination use with MTX per labeling; added prevention of concomitant use with pegadricase; extended initial approval duration from 6 to 12 months for Medicaid and HIM; references reviewed and updated
CP.PHAR.181
 Hemin (Panhematin) 06/01/2026 1Q 2026 annual review: added off-label indication for prevention of porphyria attacks; for acute porphyria continued therapy, added criterion to ensure member has not received more than 14 days of treatment; references reviewed and updated.
CP.PHAR.207
Glycerol Phenylbutyrate (Ravicti) 06/01/2026 1Q 2026 annual review: added redirection to generic glycerol phenylbutyrate; added requirement for dietary protein restriction per labeling; extended initial approval duration from 6 to 12 months; references reviewed and updated.
CP.PHAR.208
 Sodium Phenylbutyrate (Buphenyl, Pheburane, Olpruva) 06/01/2026 1Q 2026 annual review: RT4: added pediatric age extension to 1 year old for Olpruva; added requirement for dietary protein restriction per labeling; extended initial approval duration from 6 to 12 months; references reviewed and updated.
CP.PHAR.214
Desmopressin Acetate (DDAVP, Stimate, Nocdurna) 06/01/2026 1Q 2026 annual review: no significant changes; added step therapy bypass for IL HIM per IL HB 5395; for hemophilia and VWD surgical/acute bleeding, revised approval duration to 3 months and for Medicaid/HIM initial approval durations for all other indications, revised approval durations from 6 months to 12 months; references reviewed and updated.
CP.PHAR.296
 Pegfilgrastim (Neulasta and biosimilars) 06/01/2026 Per December SDC replaced Nyvepria with Fulphila as a preferred biosimilar.
CP.PHAR.332
Pasireotide (Signifor, Signifor LAR) 06/01/2026 Per December SDC, added redirection to all of the following: lanreotide, octreotide acetate LAR (generic Sandostatin LAR Depot), and brand Sandostatin LAR Depot if octreotide acetate LAR (generic Sandostatin LAR Depot) is unavailable due to shortage; removed Signifor LAR from non-formulary list which references usage of the formulary exception policy (HIM.PA.103).
CP.PHAR.370
 Emicizumab-kxwh (Hemlibra) 06/01/2026 1Q 2026 annual review: revised provider confirmation of discontinuation of bypassing agents and FVIII products as prophylaxis to exclusion for concurrent use of hemophilia prophylaxis agent with more examples; added step therapy bypass for IL HIM per IL HB 5395; for Medicaid/HIM lines of business, revised initial approval durations from 6 months to 12 months; references reviewed and updated.
CP.PHAR.389
Pegvisomant (Somavert) 06/01/2026 Per December SDC, revised somatostatin analog redirection to failure of all of the following: lanreotide, octreotide acetate LAR (generic Sandostatin LAR Depot), and brand Sandostatin LAR Depot if octreotide acetate LAR (generic Sandostatin LAR Depot) is unavailable due to shortage.
CP.PHAR.391
 Lanreotide (Somatuline Depot) 06/01/2026 Per December SDC, for all indications, added redirection to octreotide acetate LAR (generic Sandostatin LAR Depot), added redirection to brand Sandostatin LAR Depot if octreotide acetate LAR is unavailable due to shortage, added member must use generic lanreotide if available for Somatuline Depot requests.
CP.PHAR.40
Octreotide Acetate (Sandostatin, Sandostatin LAR Depot, Mycapssa) 06/01/2026 1Q 2026 annual review: added off-label criteria for Merkel cell carcinoma per NCCN; revised language for Sandostatin LAR requests, from “member has received Sandostatin Injection” to “member will receive Sandostatin Injection”; for Medicaid/HIM, extended initial approval duration from 6 to 12 months for this maintenance medication for a chronic condition; extended approval duration for mycapssa for acromegaly for commercial line of business to 12 months; references reviewed and updated. Per December SDC, for Mycapssa, revised redirection to lanreotide or generic octreotide acetate LAR, added redirection to brand Sandostatin LAR Depot if generic octreotide acetate LAR is unavailable due to shortage; for all indications, added member must use generic octreotide acetate LAR for brand Sandostatin LAR requests, added member must use generic octreotide acetate for Sandostatin Injection for continued therapy; removed Mycapssa from non-formulary list which references usage of the formulary exception policy (HIM.PA.103).
CP.PHAR.421
 Onasemnogene Abeparvovec (Zolgensma, Itvisma) 06/01/2026 RT4: added newly approved dosage form, Itvisma, with the following revisions: added documentation for inability to walk independently per study protocol; defined advanced SMA for 2 years and older; added SMA type 4 in section III; required 2 or 3 SMN2 copies.
CP.PHAR.450
Luspatercept-aamt (Reblozyl) 06/01/2026 1Q 2026 annual review: for MDS with ring sideroblasts 200 mU/mL per NCCN and added oncology step bypass; added step therapy bypass for IL HIM per IL HB 5395; revised Medicaid/HIM initial approval duration for myelofibrosis-associated anemia and continued approval durations for TDT and MDS to 12 months; revised Commercial approval durations for myelofibrosis-associated anemia initial approval and all continued therapy indications to “6 months or to the member’s renewal date, whichever is longer”; references reviewed and updated.
CP.PHAR.457
 Givosiran (Givlaari) 06/01/2026 1Q 2026 annual review: revised criterion regarding recurrent porphyria attacks from “≥ 2 attacks in 6-month period” to “4 attacks per year” per AGA guidelines; added criterion, “Panhematin, as a prophylactic treatment, is not prescribed concurrently with Givlaari” to continued therapy; extended initial approval duration from 6 to 12 months for this maintenance medication for a chronic condition; references reviewed and updated.
CP.PHAR.499
Lonafarnib (Zokinvy) 06/01/2026 1Q 2026 annual review: added safety criteria regarding hx of arrhythmias and QTc threshold per labeling updates; extended initial approval duration from 4 months for new starts to 12 months; references reviewed and updated.
CP.PHAR.516
 Fostemsavir (Rukobia) 06/01/2026 1Q 2026 annual review: extended initial approval duration from 6 months to 12 months for this maintenance medication for a chronic condition; references reviewed and updated.
CP.PHAR.574
Sirolimus Protein-Bound Particles (Fyarro), Topical Gel (Hyftor) 06/01/2026 1Q 2026 annual review: per competitor analysis, for facial angiofibroma associated with tuberous sclerosis added requirement that member has three or more facial angiofibromas that are at least 2 mm in diameter with redness in each; for PEComa revised initial approval duration for Medicaid/HIM to 12 months and for commercial “6 months or to the member’s renewal date, whichever is longer”; references reviewed and updated.
CP.PHAR.58
 Denosumab (Prolia, Xgeva), Denosumab-bbdz (Jubbonti, Wyost), Denosumab-dssb (Ospomyv, Xbryk), Denosumab-bmwo 06/01/2026 1Q 2026 annual review: per competitor analysis for MM, removed requirement that member is receiving or initiating therapy (e.g., chemotherapy, transplant) for symptomatic disease; for giant cell tumor of the bone, added additional approval pathway for resectable disease where surgical resection is likely to result in severe morbidity; for initial approval revised approval duration for Medicaid/HIM from 6 to 12 months for all oncology related indications; RT4: added new biosimilars Osvyrti and Jubereq to criteria; references reviewed and updated. Per December SDC, added Bilprevda as an additional preferred biosimilar.
CP.PHAR.595
Eladocagene Exuparvovec-tneq (Kebilidi) 06/01/2026 1Q 2026 annual review: restricted Kebilidi to age < 11 years and member is unable to ambulate independently with or without assistive device based on current available evidence; references reviewed and updated.
CP.PHAR.604
 Futibatinib (Lytgobi) 06/01/2026 1Q 2026 annual review: added 16 mg tablet strength; added minimum dose of 12 mg per day per PI; extended initial approval duration from 6 months to 12 months for this maintenance medication for a chronic condition; references reviewed and updated.
CP.PHAR.616
Zilucoplan (Zilbrysq) 06/01/2026 1Q 2026 annual review: clarified that the required immunosuppressive therapy should be non-steroidal; added Imaavy and Vyvgart Hytrulo to the list of therapies that Zilbrysq should not be prescribed concurrently with; for Medicaid and HIM, extended approval durations from 6 to 12 months and for Commercial, revised approval durations to include “or to the member’s renewal date, whichever is longer” as gMG is a chronic condition; added step therapy bypass for IL HIM per IL HB 5395; references reviewed and updated.
CP.PHAR.706
 Fitusiran (Qfitlia) 06/01/2026 1Q 2026 annual review: revised provider confirmation of discontinuation of bypassing agents and factor products as prophylaxis to exclusion for concurrent use of hemophilia prophylaxis agent with more examples; added step therapy bypass for IL HIM per IL HB 5395; for Medicaid and HIM, revised initial approval duration from 6 months to 12 months; references reviewed and updated.
CP.PHAR.707
Revumenib (Revuforj) 06/01/2026 1Q 2026 annual review: added requirement for use as a single agent; extended initial approval duration from 6 months to 12 months for this maintenance medication for a chronic condition; references reviewed and updated. RT4: added new FDA approved indication for AML with NPM1 mutation.
CP.PHAR.708
 Sepiapterin (Sephience) 06/01/2026 1Q 2026 annual review: added adherent to Phe-restricted diet per labeling and plan feedback; added step therapy bypass for IL HB 5395; references reviewed and updated.
CP.PHAR.713
Zenocutuzumab-zbco (Bizengri) 06/01/2026 1Q 2026 annual review: extended initial approval duration for HIM/Medicaid from 6 to 12 months; added minimum LVEF requirements per labeling; references reviewed and updated.
CP.PHAR.751
 Rilzabrutinib (Wayrilz) 06/01/2026 Per December SDC, added redirection to generic Promacta for ITP, removed redirection to immune globulin if intolerant or contraindicated to systemic corticosteroid.
CP.PHAR.755
Paltusotide (Palsonify) 06/01/2026 Per December SDC, added redirection to Mycapssa and one of lanreotide or generic octreotide acetate LAR (or brand Sandostatin LAR Depot if generic octreotide acetate LAR is unavailable due to shortage).
CP.PHAR.97
 Eculizumab (Soliris, Bkemv, Epysqli) 06/01/2026 Per December SDC, added redirection to Ultomiris.
CP.PMN.186
 Cenegermin-bkbj (Oxervate) 06/01/2026 1Q 2026 annual review: added diagnostic requirement for documented evidence of decreased corneal sensitivity; added requirement that disease is refractory to at least one conventional non-surgical treatment; for continuation of therapy, for a second 8 week treatment course added requirement that member did not achieve complete corneal healing or has recurrence of neurotrophic keratitis in the affected eye that requires retreatment; for initial approval criteria added requirement if member previously received Oxervate, member has not received ≥ 16 weeks total of Oxervate treatment per affected eye; references reviewed and updated.
CP.PMN.189
 Sarecycline (Seysara) 06/01/2026 1Q 2026 annual review: added step therapy bypass for IL HB 5395; added requirement for non-nodular and moderate-to-severe acne per labeling; references reviewed and updated.
CP.PMN.212
 Bedaquiline (Sirturo) 06/01/2026 1Q 2026 annual review: revised age limit for use with pretomanid down to 14 years of age (from 15 years) per IDSA; removed allowance for use up to 9 months as these extended regimens only recommend bedaquiline be used for 24-26 weeks, not the entire extended treatment duration; per template added requirement that “request does not exceed health plan-approved quantity limit, if applicable”; references reviewed and updated.
CP.PMN.222
 Pretomanid 06/01/2026 1Q 2026 annual review: revised age limit down to 14 years of age (from 15 years) per IDSA; references reviewed and updated.
CP.PCH.06
 Valganciclovir (Valcyte) 06/01/2026 1Q 2026 annual review: for CMV retinitis, changed approval duration from 4 months to 3 months per CDC guidance; added request does not exceed health plan-approved quantity limit, if applicable; references reviewed and updated.
CP.PCH.53
 Leuprolide Acetate (Eligard, Fensolvi, Lupron Depot, Lupron Depot-Ped, Vabrinty), Leuprolide Mesylate (Camcevi, Camcevi ETM) 06/01/2026 Added Vabrinty to policy per SDC request.
HIM.PA.161
 Human Growth Hormone (Somapacitan, Somatrogon, Somatropin) 06/01/2026 1Q 2026 annual review: removed Zorbtive from policy due to market discontinuation; removed criteria for short bowel syndrome due to lack of support by AGA; for HIV-associated wasting, added option for unintentional weight loss of ≥ 5% in the last 6 months while on antiretroviral and removed use of ideal body weight criteria per update 2024 consensus expert statement; added step therapy bypass for IL HIM per IL HB 5395; extended initial approval duration from 6 to 12 months for this maintenance medication for a chronic condition; references reviewed and updated.
HIM.PA.175
 Mepolizumab (Nucala) 06/01/2026 1Q 2026 annual review: for COPD, revised blood eosinophil count requirement from “≥ 150 cells/µL at time of request or ≥ 300 cells/µL in the past 12 months” to “≥ 300 cells/µL” per 2026 GOLD COPD guidelines; added step therapy bypass for IL HIM per IL HB 5395; references reviewed and updated.
HIM.PA.91
 Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors 06/01/2026 1Q 2026 annual review: for diabetes, revised canagliflozin-containing product bypass for trials of preferred SGLT2 inhibitors to require dapagliflozin for members with multiple risk factors for CV disease; added step therapy bypass for IL HIM per IL HB 5395; references reviewed and updated.
For questions about QualChoice Medical Coverage Policies, please contact your Provider Relations Representative at 800.235.7111 or 501.228.7111, Monday through Friday, 8:00 a.m. to 5:00 p.m.
QCA26-AR-H-018